Employee Information Form - People Incorporated
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1
2Today’s Date___________
EMPLOYEE INFORMATION FORM
FULL NAME: _____________________________________________________________________________________
Last
First
Middle
GENDER: Male Female
DATE OF BIRTH: ______/______/19_____
SOCIAL SECURITY: _______-_______-_______
MARITAL STATUS: ___single ___ married ___divorced ___widowed
HIGHEST LEVEL OF EDUCATION_____________________ LICENSE # (If applicable) _________________________
ADDRESS: ______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
City
State
Zip
County
PHONE NUMBER: (_____)________________________V (_____)_______________________TTY
CELL PHONE: (____)____________________________________________________________
EMAIL ADDRESS: ______________________________________________________________
SPOUSE/PARTNER NAME: ______________________________________________________
First
Last
DEPENDENTS:
NAME
RELATION
BIRTHDATE
STUDENT?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
ETHNICITY:
___White
___Asian
___Native Hawaiian or Other Pacific Islander
___Hispanic or Latino
___Black or African American
___Two or more races
___American Indian or Alaska Native
___I do not wish to identify
DISABLED:
___yes
___no
**See page 2 for definition of a disability**
VETERAN SATUS:
V
100
ETS
Vietnam Era Veteran: ___ yes ___ no
Special Disabled Veteran: ___ yes ___ no
Other Protected Veteran: ___ yes ___ no
Recently Separated Veteran (1 year) ___ yes ___ no
V
100A
ETS
Armed Forces Service Meal Veteran: ___ yes ___ no
Disabled Veteran: ___ yes ___ no
Other Protected Veteran: ___ yes ___ no
Recently Separated Veteran (3 yrs) ___ yes ___ no
Discharge Date: _________________
C:\Documents and Settings\Leslie.DeBoer\Local Settings\Temporary Internet Files\Content.Outlook\LNMY7NQ3\Empl Info 3 12.doc
Page 1 of 2 Revised: March 2012
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Parent category: Business